Chapter 8 Nor'easter

The nor'easter came in on Wednesday afternoon, two days after Rhys asked me how old they were, and it announced itself as sleet thrown against my office window by the handful.

The harbor cranes had vanished into it. I turned my back on the window and pulled Edmund's echocardiogram up on both monitors.

On the left screen, Trent Kemp's note from January. Four lines. Severe aortic stenosis, critical. Patient frail, aphasic, poor functional status. Not a candidate for surgical or transcatheter intervention. Inoperable. Palliative management advised.

On the right screen, the pictures.

I watched the valve open and close forty times. I measured it myself, twice, as Ingrid Sommer had taught me: never trust another surgeon's numbers when you can take your own.

The valve was thickened and stiff, the leaflets bright with calcium. But it opened. The area came out at a little over a square centimeter. The pressure across it was raised, but not high. The left ventricle was squeezing well.

Moderate. A valve to watch. A valve you'd check again in six months and probably again in a year. Not a valve you'd write inoperable on, because there was nothing to operate on yet.

Kemp hadn't misread it. You don't misread a scan like this by accident. He'd written down the most frightening word he could find, and nobody had checked.

Then I opened the medication record, and I stopped humming.

Digoxin 62.5 mcg daily. Metoprolol. Apixaban. All sensible. Lorazepam 1 mg three times daily. Scheduled. Every day, for five years. Below it: Lorazepam 0.5 mg PRN agitation, max 2 mg/24h. Prescriber: Dr. Gordon Stroud. Administered and charted, every dose, by U. Blythe, RN.

I scrolled down the administration log. The PRN doses weren't occasional. They were daily. Some days twice. Some days three times. Always the same small, neat initials in the column.

I thought of his lids drooping as soon as I stopped talking. The slow drift after the penlight, and the coarse jerk back. He gets terribly agitated without it, Ursula had said, and closed her notebook.

You didn't need to be a genius. You only needed to look.

I wrote my consult note slowly, because a note is a permanent thing and somebody always reads it later in a worse mood than yours. Aortic stenosis, moderate on my measurements, not critical. No indication for intervention at present. Repeat echo six months.

Then the paragraph that mattered. Exam shows heavy lids, glassy affect, horizontal nystagmus on lateral gaze, consistent with sedative effect. Patient able to follow commands and answer yes/no reliably. Recommend urgent medication review, specifically benzodiazepine load, with a view to supervised reduction.

I signed it. Then I picked up the phone.

Dr. Gordon Stroud answered on the seventh ring. He sounded like a man who'd been interrupted at lunch and intended to make it someone's problem.

"Nobody consulted me," he said, when I'd explained who I was.

"I'm consulting you now. Mr. Calloway's showing signs of oversedation. I'd like to talk about his lorazepam."

"Mr. Calloway has been my patient for five years. He's post-stroke, aphasic and prone to violent agitation. His regimen is appropriate."

"He squeezed my hand on command eleven times in a row on Monday. He didn't look violent. He looked drugged."

There was a short, dense silence.

"Dr. Fairley," Stroud said, "you've been in this country for four days. I suggest you stick to valves." And he hung up.

I put the phone down gently, because the alternative was not gently.

---

Heart team met at four in the sixth-floor conference room: a wall screen, two cardiologists, an anesthetist, four residents with laptops, and a plate of cookies nobody touched. Okafor sat at the head. Kemp sat at his right hand, tanned and relaxed, his chair pushed back from the table.

Edmund's case was third on the list. Okafor had put it there himself.

"Calloway," he said. "Dr. Fairley saw him on Monday."

Kemp spread his hands before I'd stood up. "Winston, with respect, we went through this in January. I examined the man. Critical stenosis, eighty-five, post-stroke, aphasic. The family has been counseled. Let's not drag them through it again."

"Agreed," I said. I plugged my laptop into the wall screen. "Can we look at the January study?"

The valve came up, opening and closing on its loop, twelve feet wide. Calcium glittered on the leaflets.

"There," said Kemp. "Look at that calcium."

"It's calcified. It's also opening." I took the cursor and traced the outflow tract below the valve, then laid the Doppler trace beside it. The numbers dropped into the corner of the screen as I worked. "Outflow diameter, two centimeters. Peak velocity across the valve, three point three meters a second. Mean gradient twenty-four. Continuity equation gives a valve area of one point one."

One of the residents stopped typing.

"Severe starts below one," I said. "What Dr. Kemp has written as critical, I'd expect to see under point six, with a gradient over forty. The ventricle's squeezing normally, so the gradient isn't falsely low. This is moderate stenosis. There's nothing here to operate on, and nothing here that makes him inoperable. He needs an echo in six months."

"Calcium shadow," Kemp said. "You're underestimating the gradient. Any first-year knows the Doppler angle—"

"Then measure it." I held out the mouse to him, across the table. "Take your own numbers. I'll wait."

He didn't take it. The mouse sat between us on the laminate with its little red light on.

Nobody said anything. One of the cardiologists had pulled the study up on his own laptop and was tracing it himself, his lips moving. He sat back, and looked at Okafor, and gave the smallest nod.

Okafor took his glasses off.

"In January," he said, to nobody in particular, "this hospital told a family their grandfather had a few months to live. On the strength of a note that says critical." He put the glasses on the table. "Dr. Kemp, you'll amend your note today. Dr. Fairley's measurements go on the record as the department's assessment." He turned a page in his folder. "Next case."

Kemp's smile had stayed where it was. It was only his neck that went red, from the collar up, in a slow tide. He pulled his chair in to the table, and reached for a cookie, and didn't eat it.

I unplugged my laptop and sat down. I didn't look at him. I didn't need to. Four residents had already written the number down.

---

Okafor stopped by my door at six, coat already on, a squashed umbrella in one hand.

"Stroud called me," he said. "He used the word 'impertinent.' Twice."

"I'm sorry."

"Don't be. Gordon Stroud has been calling me impertinent since 1998." He glanced at my screens, where the valve was still opening and closing on its loop. "I read your note. The second paragraph." He tucked the umbrella under his arm. "Keep writing like that. Every dose, every name. Someone will want to read it later."

"Yes, sir."

"And Dr. Fairley." He paused in the doorway. "Go home. Your children have been in a new country for four days, and there's a storm."

---

By eight that night, the storm had parked itself over Old Harbor and seemed to mean to buy property.

Helen's house had been built in 1880 by a man who mended nets for a living, and it had opinions about weather. The windows rattled in their frames. At a quarter to nine the lights dimmed to brown, flickered twice, and came back.

"Again," said Pippa, from inside the fort. "Do it again, lights."

She'd built the fort out of every cushion in the house and the dining chairs and two of Helen's old quilts, and she and Admiral were inside it with a flashlight conducting what she said was a shark meeting.

Felix was sitting on the kitchen floor in his pajamas with his knees drawn up, watching the ceiling.

The roof had a leak over the back of the kitchen. It had been there when I was nine. Helen had never fixed it; she'd said it was the house's way of crying. I'd put a stockpot under it on a folded towel, and every few seconds a drop gathered on the ceiling, swelled, let go, and hit the water with a small clear note.

"Forty-one," Felix said, under his breath. "Forty-two."

"Bed in five minutes, love."

"Forty-three." He frowned up at the drip. "It's going faster."

"That's the storm. It'll slow down when the wind drops."

"Forty-four."

"Mama?" The quilt stopped bulging. "Is the grumpy man from the airport the same as the grumpy man from the hospital?"

I'd been waiting for it since Monday. I still wasn't ready.

"Why do you ask?"

"Felix says." Pippa's head came out, then Admiral's. "Felix says the magazine man and the hospital man have the same face. I said magazines aren't real people. Felix says they are."

On the kitchen floor, Felix had stopped counting. He was watching me with his gray eyes, the eyes that were mine, and waiting for me to tell him the truth, because I always had.

"Some magazines have real people in them," I said. "Yes. It's the same man."

"Why was he in the magazine?"

"Because he runs a big company. The one with the cranes."

Pippa thought about this. "Is he famous?"

"In Bramport."

"Hm." She disappeared back into the fort. "He didn't look famous. He looked like he needed a nap."

Felix looked back up at the ceiling and found his place. "Forty-five," he said.

Somebody banged on the front door.

Three bangs, with the flat of a hand. Pippa stuck her head out of the fort, curls everywhere. Felix stopped counting.

I knew who it was before I opened it. Nobody else I knew in Bramport would have come out in that weather and not phoned first.

Rhys was on the step, soaked through. No umbrella, no hat, his dark coat black with water, sleet melting on his shoulders. Behind him in the street his car sat with its lights on and the engine running.

"I filed," he said. "Paternity, custody and a DNA order. You'll be served."

The wind drove a fistful of sleet past him into the hall.

"You came here at nine o'clock at night in a nor'easter," I said, "to tell me that."

"I came to tell you to your face. I'm not doing it the way you did it."

I let that go past me. I'd had five years of practice.

I didn't step back. I didn't invite him in. I stood in the narrow hall in my old sweater and socks, my body between him and the stairs, and I lowered my voice.

"You've seen them," I said. "That's the visit."

"They're my children."

"You don't know that."

"Don't." His voice went harder. "Don't do that. I can count."

"Then count this." I held the door. "It's a school night. They're four. Their mother has been at work for twelve hours. A man they've met once, who shouted in a hospital room, is standing in the rain banging on the door. Whatever you think your rights are, they don't start tonight."

Water was running off his chin. He didn't wipe it away.

"I didn't shout," he said.

"You didn't have to."

"When can I see them?"

"When a judge tells me you can. You've filed. That was your choice. Now we do it your way, with lawyers and forms and a stranger in a robe deciding what's best for two children he's never met." I kept my hand on the door. "You wanted it on paper, Rhys. You always do."

---

"You're grumpy."

We both looked up.

Pippa was sitting on the fourth step from the bottom with Admiral in her lap. My step. She was in her shark pajamas, the ones with the fins on the back of the hood, and she'd put the hood up.

She was studying Rhys with her chin on her fists and her green eyes narrowed, exactly as she studied a new food before deciding whether it was going to be allowed in her mouth.

"Pippa," I said. "Bed."

"I'm deciding." She went on looking at him. Rhys looked back at her. He seemed to have forgotten about the rain entirely.

"Actually," Pippa said, "you're the grumpiest man in America."

Rhys opened his mouth, and nothing came out.

I'd seen him face down a union boss, a port commissioner and his own father. I had never seen him have nothing to say.

He stood dripping on Helen's doormat, looking at a four-year-old in a shark hood, and his face was completely blank.

"Admiral agrees," Pippa added.

Something moved behind her on the stairs.

Felix came down. He came one step at a time, holding the banister with one hand, the blue stethoscope around his neck, his bare feet silent on the carpet. He had eyes for nobody on that staircase. He was watching Rhys's chest.

"Felix," I said.

He came past me without a glance, and stopped in front of Rhys, and put the earpieces in his ears.

Rhys's coat hung open. His shirt underneath was soaked through and stuck to him. Felix reached up, as high as he could, and pressed the round bell of the stethoscope flat against the wet cotton, over the left side of Rhys's chest.

Rhys didn't move. He stood there in the open doorway with the storm at his back and let a four-year-old listen to his heart. His hands were at his sides. I saw them close, slowly, and stay closed.

Felix listened with his eyes on the floor, his lips moving as he counted. The wind blew sleet into the hall. In the kitchen the drip hit the pot, and hit it again.

Then Felix took the earpieces out. He turned around and went back up the stairs to his sister and leaned close to her ear, and whispered it loudly enough that we both heard.

"His heart's going fast," Felix whispered to Pippa.